Domain : iz
Version :
Date : 2016-01-21 13:51:02
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Acosta |
| ID Number | 123456 |
| Date/Time of Birth | 11/01/2010 11:05 |
| Sex | Female |
| Patient Address | 4345 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1212 |
| Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Acosta |
| ID Number | 123456 |
| Date/Time of Birth | 11/01/2010 11:05 |
| Sex | Female |
| Patient Address | 4345 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1212 |
| Birth Indicator | No |
| Birth Order |
| Description |
|---|
| The vendor will receive information back from the registry and show the ability to view and reconcile, and import the information returned by the registry (NOTE: the Z42 message will be provided either manually, or as part of the tool). This test will also look at the system's ability to view the forecast returned by the registry, and create a new forecast after reconciling the information. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
The Immunization Registry returns an Evaluated History and Forecast (Z42) to the EMR in response to the query for patient (Juana Mariana Gonzales). The provider reviews the immunization history from the registry and compares to the immunization history in the EMR. The provider reconciles the information from these sources, importing information known only to the registry, retaining information that is more accurately reflected in the local EMR: The physician accesses the record for Juana Mariana Gonzales and: • Reconciles the EHR vaccine history with the history retrieved from the registry: o Accepts new vaccines from the registry data o If the EHR does not already flag the first MMRV as invalid, the provider updates the first MMRV to indicate it is “invalid” as it was given too early (as notified by the registry) o Retains the local history for influenza and polio vaccines that are not included in the registry report. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR. |
| Post Condition |
|---|
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariana Gonzales) |
| Test Objectives |
|---|
Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History: The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient’s local immunization history and include the time of the update and the source of the new information. Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.).
|
| Evaluation Criteria |
|---|
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Juana Mariana Gonzales Display Reconcile Update Immunization Information | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | Juana Mariana Gonzales | |
| Date of Birth | 11/01/2010 | |
| Sex | Female | |
| Address 1 | ||
| Street | 4345 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Maria Merida Acosta | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/01/2010 | |
| Date/Time Administration-End | 11/01/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, unspecified formulation | |
| Refusal Reason | ||
| Date/Time Administration-Start | 12/20/2010 | |
| Date/Time Administration-End | 12/20/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/20/2011 | |
| Date/Time Administration-End | 05/20/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2011 | |
| Date/Time Administration-End | 01/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2011 | |
| Date/Time Administration-End | 03/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2011 | |
| Date/Time Administration-End | 05/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 02/21/2012 | |
| Date/Time Administration-End | 02/21/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2011 | |
| Date/Time Administration-End | 01/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2011 | |
| Date/Time Administration-End | 03/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2011 | |
| Date/Time Administration-End | 05/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/21/2011 | |
| Date/Time Administration-End | 11/21/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2011 | |
| Date/Time Administration-End | 01/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2011 | |
| Date/Time Administration-End | 03/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2011 | |
| Date/Time Administration-End | 01/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2011 | |
| Date/Time Administration-End | 03/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2011 | |
| Date/Time Administration-End | 05/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/11/2012 | |
| Date/Time Administration-End | 01/11/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2011 | |
| Date/Time Administration-End | 01/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2011 | |
| Date/Time Administration-End | 03/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/25/2011 | |
| Date/Time Administration-End | 09/25/2011 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/29/2011 | |
| Date/Time Administration-End | 10/29/2011 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/02/2012 | |
| Date/Time Administration-End | 10/02/2012 | |
| Administered Amount | .25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/04/2013 | |
| Date/Time Administration-End | 11/04/2013 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/23/2011 | |
| Date/Time Administration-End | 11/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/23/2012 | |
| Date/Time Administration-End | 05/23/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Shoreline Pediatrics | |
| Vaccine Group | MMR | |
| Vaccine Administered | measles, mumps, rubella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 08/22/2011 | |
| Date/Time Administration-End | 08/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | Sandra Molina | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 400 Shoreline Drive | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | NO | |
| Validity Reason | Early | |
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | MMR | |
| Vaccine Administered | measles, mumps, rubella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/22/2014 | |
| Date/Time Administration-End | 11/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Varicella virus vaccine | |
| Vaccine Administered | varicella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 12/15/2012 | |
| Date/Time Administration-End | 12/15/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 04/30/2011 | |
| Earliest Date to Give | 04/30/2011 | |
| Latest Date to Give | 04/29/2012 | |
| Date When Vaccine Overdue | 04/30/2012 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 10/31/2014 | |
| Earliest Date to Give | 10/31/2014 | |
| Latest Date to Give | 10/30/2016 | |
| Date When Vaccine Overdue | 10/31/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 09/01/2015 | |
| Earliest Date to Give | 09/01/2015 | |
| Latest Date to Give | 01/31/2016 | |
| Date When Vaccine Overdue | 10/31/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 10/31/2014 | |
| Earliest Date to Give | 10/31/2014 | |
| Latest Date to Give | 10/30/2016 | |
| Date When Vaccine Overdue | 10/31/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 10/31/2014 | |
| Earliest Date to Give | 10/31/2014 | |
| Latest Date to Give | 10/30/2016 | |
| Date When Vaccine Overdue | 10/31/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
If the EHR does not already flag the first MMR as invalid, the provider updates the first MMR to indicate it is "invalid" as it was given too early (as notified by the registry). The next MMR is entered as given 14 days prior to the test date. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Initial Data Load |
| Post Condition |
|---|
MMR status for the first MMR dose is set to invalid. The 2nd MMR vaccination from 14 days prior to the current visit is entered into the patient record. |
| Test Objectives |
|---|
dose validity is an important aspect of: Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.
|
| Evaluation Criteria | |||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Vendor Records 2nd historical MMR dose two weeks prior to the current test date. Evaluation Criteria: The vendor is able to record that the first MMR vaccination dose is invalid with a reason that it was given too early, and therefore this new dose should be indicated as dose '1'. Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The physician accesses the record for Juana Mariana Gonzales and: • Displays the registry forecast which includes the need for a second, valid MMRV vaccine and also the need for influenza and polio vaccines (since the registry has no information about them) |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR. |
| Post Condition |
|---|
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariana Gonzales) |
| Test Objectives |
|---|
View Immunization Forecast: The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, ideal date, and maximum (latest) date for each vaccine included in the forecast. |
| Evaluation Criteria |
|---|
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. 2. Verify that All forecast vaccines and dates returned by the registry are displayed to the user. |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Juana Mariana Gonzales Display Reconcile Update Immunization Information | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | Juana Mariana Gonzales | |
| Date of Birth | 11/01/2010 | |
| Sex | Female | |
| Address 1 | ||
| Street | 4345 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Maria Merida Acosta | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/01/2010 | |
| Date/Time Administration-End | 11/01/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, unspecified formulation | |
| Refusal Reason | ||
| Date/Time Administration-Start | 12/20/2010 | |
| Date/Time Administration-End | 12/20/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/20/2011 | |
| Date/Time Administration-End | 05/20/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2011 | |
| Date/Time Administration-End | 01/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2011 | |
| Date/Time Administration-End | 03/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2011 | |
| Date/Time Administration-End | 05/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 02/21/2012 | |
| Date/Time Administration-End | 02/21/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2011 | |
| Date/Time Administration-End | 01/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2011 | |
| Date/Time Administration-End | 03/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2011 | |
| Date/Time Administration-End | 05/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/21/2011 | |
| Date/Time Administration-End | 11/21/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2011 | |
| Date/Time Administration-End | 01/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2011 | |
| Date/Time Administration-End | 03/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2011 | |
| Date/Time Administration-End | 01/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2011 | |
| Date/Time Administration-End | 03/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2011 | |
| Date/Time Administration-End | 05/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/11/2012 | |
| Date/Time Administration-End | 01/11/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2011 | |
| Date/Time Administration-End | 01/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2011 | |
| Date/Time Administration-End | 03/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/25/2011 | |
| Date/Time Administration-End | 09/25/2011 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/29/2011 | |
| Date/Time Administration-End | 10/29/2011 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/02/2012 | |
| Date/Time Administration-End | 10/02/2012 | |
| Administered Amount | .25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/04/2013 | |
| Date/Time Administration-End | 11/04/2013 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/23/2011 | |
| Date/Time Administration-End | 11/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/23/2012 | |
| Date/Time Administration-End | 05/23/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Shoreline Pediatrics | |
| Vaccine Group | MMR | |
| Vaccine Administered | measles, mumps, rubella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 08/22/2011 | |
| Date/Time Administration-End | 08/22/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | Sandra Molina | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 400 Shoreline Drive | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | NO | |
| Validity Reason | Early | |
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | MMR | |
| Vaccine Administered | measles, mumps, rubella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/22/2014 | |
| Date/Time Administration-End | 11/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Varicella virus vaccine | |
| Vaccine Administered | varicella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 12/15/2012 | |
| Date/Time Administration-End | 12/15/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 04/30/2011 | |
| Earliest Date to Give | 04/30/2011 | |
| Latest Date to Give | 04/29/2012 | |
| Date When Vaccine Overdue | 04/30/2012 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 10/31/2014 | |
| Earliest Date to Give | 10/31/2014 | |
| Latest Date to Give | 10/30/2016 | |
| Date When Vaccine Overdue | 10/31/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 09/01/2015 | |
| Earliest Date to Give | 09/01/2015 | |
| Latest Date to Give | 01/31/2016 | |
| Date When Vaccine Overdue | 10/31/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 10/31/2014 | |
| Earliest Date to Give | 10/31/2014 | |
| Latest Date to Give | 10/30/2016 | |
| Date When Vaccine Overdue | 10/31/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 10/31/2014 | |
| Earliest Date to Give | 10/31/2014 | |
| Latest Date to Give | 10/30/2016 | |
| Date When Vaccine Overdue | 10/31/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
Juana Maria Gonzales Morales immunization registry provided Evaluated History and Forecast is reconciled with the Immunization history information in the EMR. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import. |
| Post Condition |
|---|
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariana Gonzales) |
| Test Objectives |
|---|
Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. |
| Evaluation Criteria |
|---|
1. The user imports returned vaccinations as follows: a. Vaccinations NOT imported: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 12/20/2010 measles, mumps, rubella, and varicella virus vaccine (CVX 94) administered 8/22/2011 VERIFY that the dose validity is marked as invalid b. Vaccinations Imported: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 11/01/2010 hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 05/20/2011 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 1/22/2011 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 3/23/2011, Including adverse reaction 31044-1 Reaction, VXC12^fever of >40.5C (105F) within 48 hours of dose diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/22/2011 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 2/21/2012 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 1/21/2011 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 3/23/2011 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/22/2011 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 11/21/2011 poliovirus vaccine, inactivated (CVX 10) administered 1/22/2011 poliovirus vaccine, inactivated (CVX 10) administered 3/23/2011 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/22/2011 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 3/23/2011 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/22/2011 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/11/2012 rotavirus, live, monovalent vaccine (CVX 119) administered 1/22/2011 rotavirus, live, monovalent vaccine (CVX 119) administered 3/23/2011 Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 9/25/2011 Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/29/2011 Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/2/2012 Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 11/4/2013 hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 11/23/2011 hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 5/23/2012 measles, mumps, rubella virus vaccine (CVX 94) administered 11/22/2014 Varicella virus vaccine (CVX 94) administered 12/15/2012 |
| Notes for Testers |
|---|
No Note |
| Description |
|---|
Once the vaccine history is reconciled in the EMR, the vaccine forecast is updated. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
EMR Vaccine History is Reconciled with Immunization History from the IIS (previous step 'Reconcile and import vaccinations from Evaluated History and Forecast returned by the Registry for Juana Mariana Gonzales'). |
| Post Condition |
|---|
An updated vaccine forecast based upon the reconciled vaccine history is available to the user. |
| Test Objectives |
|---|
View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient’s newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. |
| Evaluation Criteria |
|---|
Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history: 1. Verify that the EMR does not include in reconciled vaccine forecast: IPV due on 4/30/2011 2. Verify that the EMR includes in reconciled vaccine forecast: IPV due on 10/31/2014 MMR due on 10/31/2014 Varicella due on 10/31/2014 influenza, unspecified formulation due on 09/01/2015 |
| Notes for Testers |
|---|
No Note |
| Description |
|---|
| This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
| The physician accesses the record for Juana Mariana Gonzales and: • Selects order for IPV and views information about the prior febrile seizure post-IPV vaccine |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. |
| Post Condition |
|---|
IPV order entered in patient record. User notified of history of adverse reaction to IPV (febrile seizures). |
| Test Objectives |
|---|
Notify of Previous Adverse Event: EHRs and other clinical software systems alert providers to previous adverse events for a specific patient, in order to inform clinical decision-making when providers view an existing immunization record. |
| Evaluation Criteria | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following order information and Alert:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
| The mother is concerned about administering the IPV due to the prior adverse reaction, and refuses to have the child immunized for IPV. The provider documents mother’s refusal for IPV vaccine indicating the parent decision, the reason and makes it permanent. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Prior Immunization History loaded and reconciled from the Immunization Registry. Order is attempted for IPV. Provider has been alerted to prior adverse reaction to IPV of febrile seizures. |
| Post Condition |
|---|
Vaccine non-administration due to parental refusal is documented in the patient record. Deferral is permanent. |
| Test Objectives |
|---|
Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed. |
| Evaluation Criteria | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
EMR documents the non-administration of the IPV due to the parental refulsal:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
| The provider orders inactivated influenza vaccine and is notified that the patient as allergy to egg albumin |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. |
| Post Condition |
|---|
| Intranasal form of the Influenza vaccine is ordered for the patient. |
| Test Objectives |
|---|
| Modify Antigen Recommendations Based on Allergy History: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient’s active allergies. |
| Evaluation Criteria | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following order information and Alert:
Provider changes the order to modifies the Vaccine type:
|
| Notes for Testers |
|---|
No Note |
The provider attempts to order a Varicella dose and is alerted that it is too soon to give a live virus following the MMR dose 14 days prior.
| Description |
|---|
| The provider attempts to give a Varicella dose, and is warned that it is too soon to give a live vaccine dose. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. MMR dose entered at 14 days prior to the current date. |
| Post Condition |
|---|
| The provider has been issued a warning that it is too soon to give another live virus dose. |
| Test Objectives |
|---|
| Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required. |
| Evaluation Criteria |
|---|
| There should be a warning that the attempt to give a new Varicella Dose is too early - should get warning that 28 days must pass between 2 live virus vaccines if not administered at the same time due to the prior MMR vaccination 14 days earlier. |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
The nurse documents administration route for the nasal live, attenuated influenza vaccine |
| Comments |
|---|
This step covers data quality checking as an informative aspect of vaccine administration |
| Pre Condition |
|---|
Order is placed for nasal live, attenuated influenza vaccine. |
| Post Condition |
|---|
The nasal live, attenuated influenza vaccination route has failed to be recorded as intramuscular in the EMR. |
| Test Objectives |
|---|
Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria |
|---|
The EMR prevents the user for entering 'Intramuscular' as a route for the the nasal live, attenuated influenza vaccine. |
| Notes for Testers |
|---|
No Note |
| Description |
|---|
|
The nurse administers the the nasal live, attenuated influenza vaccine
|
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| Order is placed for nasal live, attenuated influenza vaccine. |
| Post Condition |
|---|
| The nasal live, attenuated influenza vaccinations is recorded in the EMR. |
| Test Objectives |
|---|
| Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following vaccine administration information:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The nurse documents administration route for the MMRV vaccine |
| Comments |
|---|
This step covers data quality checking as an informative aspect of vaccine administration |
| Pre Condition |
|---|
Order is placed for MMRV vaccine. |
| Post Condition |
|---|
The MMRV vaccination route has failed to be recorded as 'oral' in the EMR. |
| Test Objectives |
|---|
Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria |
|---|
The EMR prevents the user for entering 'Oral' as a route for the the MMRV vaccine. |
| Notes for Testers |
|---|
No Note |
| Description |
|---|
|
The nurse administers the the MMRV vaccine
|
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| Order is placed for MMRV vaccine. |
| Post Condition |
|---|
| The MMRV vaccination is recorded in the EMR. |
| Test Objectives |
|---|
| Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following vaccine administration information:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
| Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
| The Report must include all newly administered vaccines in any order. the report may also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS. |
| Pre Condition |
|---|
| The vaccines for the visit have been administered. |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
The Report must include all newly administered vaccines in any order. the report may also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS. |
| Pre Condition |
|---|
The vaccines for the visit have been administered. |
| Post Condition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 11/01/2010 11:05 |
| Administrative Sex | Female |
| Patient Address 1 | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/01/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 12/20/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 12/14/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 05/20/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 11/30/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 12/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 11/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2012 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2013 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | Refused |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/11/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/29/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2013 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 11/04/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 04/30/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Vaccine | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 10/15/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2016 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/04/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 08/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0853CC |
| Substance Expiration Date | 12/15/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 11/22/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 0854FF |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 10/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0934GG |
| Substance Expiration Date | 12/15/2016 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | varicella |
| Date/Time Start of Administration | 12/15/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 2341BB |
| Substance Expiration Date | 12/01/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | varicella |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 3452DD |
| Substance Expiration Date | 12/01/2016 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Right Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 11/01/2010 11:05 |
| Administrative Sex | Female |
| Patient Address 1 | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/01/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 12/20/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 12/14/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 05/20/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 11/30/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 12/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 11/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2012 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2013 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | Refused |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/11/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/29/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2013 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 11/04/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 04/30/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Vaccine | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 10/15/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2016 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/04/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 08/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0853CC |
| Substance Expiration Date | 12/15/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 11/22/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 0854FF |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 10/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0934GG |
| Substance Expiration Date | 12/15/2016 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | varicella |
| Date/Time Start of Administration | 12/15/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 2341BB |
| Substance Expiration Date | 12/01/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | varicella |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 3452DD |
| Substance Expiration Date | 12/01/2016 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Right Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Description |
|---|
Following the vaccine administration, the patient's mother reports that the patient that evening had persistent, inconsolable crying lasting > 3 hours. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
The vaccinations for the visit have been administered. |
| Post Condition |
|---|
The adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR. |
| Test Objectives |
|---|
Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events. |
| Evaluation Criteria |
|---|
Verify that vendor can record the adverse reaction of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose correctly and without omission |
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is reported to the Immunization Registry using a Z22/VXU message. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
An adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR. |
| Post Condition |
|---|
The adverse reaction has been transmitted to the IIS. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 11/01/2010 11:05 |
| Administrative Sex | Female |
| Patient Address 1 | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/01/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 12/20/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 12/14/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 05/20/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 11/30/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 12/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 11/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2012 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2013 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | Refused |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/11/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/29/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2013 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 11/04/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 04/30/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Vaccine | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 10/15/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2016 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/04/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 08/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0853CC |
| Substance Expiration Date | 12/15/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 11/22/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 0854FF |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 10/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0934GG |
| Substance Expiration Date | 12/15/2016 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | varicella |
| Date/Time Start of Administration | 12/15/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 2341BB |
| Substance Expiration Date | 12/01/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | varicella |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 3452DD |
| Substance Expiration Date | 12/01/2016 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Right Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Reaction | persistent, inconsolable crying lasting > 3 hours within 48 hours of dose |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 11/01/2010 11:05 |
| Administrative Sex | Female |
| Patient Address 1 | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/01/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 12/20/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 12/14/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 05/20/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 11/30/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 12/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 11/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2012 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2013 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | Refused |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/11/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/29/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2013 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 11/04/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 04/30/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Vaccine | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 10/15/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2016 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Nasal |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/04/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 08/22/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0853CC |
| Substance Expiration Date | 12/15/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 11/22/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 0854FF |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 10/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0934GG |
| Substance Expiration Date | 12/15/2016 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | varicella |
| Date/Time Start of Administration | 12/15/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 2341BB |
| Substance Expiration Date | 12/01/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | varicella |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 3452DD |
| Substance Expiration Date | 12/01/2016 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Right Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Reaction | persistent, inconsolable crying lasting > 3 hours within 48 hours of dose |
| Description |
|---|
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| Post Condition |
|---|
| The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| Post Condition |
|---|
| The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
The following patient demographics are displayed: Patient Identifier Number: Vendor Assigned Patient Identifier Type Code: Vendor Assigned Patient Name: Juana Mariana Gonzales Date/Time of Birth: 11/01/2010 11:05am Sex: Female Patient Address: 4345 Standish Way, Stamford, CT, 06903 Multiple Birth: N Birth Order: NA The following Vaccination History is displayed: Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 11/01/2010 Additional Observations: None Dose #: 1 Doses in Series: 3 Valid Dose: Y Ordering Provider: Jane Carter Entered By: Lisa Sirtis Entering Organization: Shoreline Hospital Administered Amt: .05 mL Administering Provider: Jane Carter Administered at Location: 325 Shorline Drive, Stamford Connecticut 06901 Lot#: 6332FK33 Exp Date: 12/14/2011 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 12/20/2010 Additional Observations: None Dose #: 2 Doses in Series: 3 Valid Dose: Y Ordering Provider: Frank Smith Entered By: Sandra Molina Entering Organization: Shoreline Pediatrics Administered Amt: .05 mL Administering Provider: Sandra Molina Administered at Location: 400 Shorline Drive, Stamford Connecticut 06901 Lot#: 6352FK1 Exp Date: 12/14/2011 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 05/20/2011 Additional Observations: None Dose #: 3 Doses in Series: 3 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: Sandra Molina Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6352FK24 Exp Date: 8/31/2012 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 1/22/2011 Additional Observations: None Dose #: 1 Doses in Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS2341 Exp Date: 11/30/2011 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01) Date Administered: 3/23/2011 Additional Observations: 31044-1 Reaction, VXC12^fever of >40.5C (105F) within 48 hours of dose Dose #: 2 Doses in Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS2433 Exp Date: 9/4/2011 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 5/22/2011 Additional Observations: Dose #: 3 Doses in Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS3255 Exp Date: 12/1/2011 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 2/21/2012 Additional Observations: Dose #: 4 Doses in Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS249 Exp Date: 3/1/2012 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 11/30/2014 Additional Observations: Dose #: 5 Doses in Series: 5 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: Sandra Molina Entering Organization: Shoreline Pediatrics Administered Amt: .05 mL Administering Provider: Linda Casera Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D643QS8243 Exp Date: 12/01/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 1/21/2011 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M54K9245 Exp Date: 3/24/2011 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 3/23/2011 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M55K3342 Exp Date: 10/30/2011 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 5/22/2011 Additional Observations: Dose #: 3 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M75K4566 Exp Date: 5/23/2011 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 11/21/2011 Additional Observations: Dose #: 4 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M53K5534 Exp Date: 2/22/2012 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55) Date Administered: 1/22/2011 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D333PV2431 Exp Date: 10/4/2011 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55) Date Administered: 3/23/2011 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D333PV4344 Exp Date: 3/23/2012 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55) Date Administered: 2/21/2012 Additional Observations: Dose #: 3 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D335PV9644 Exp Date: 2/22/2013 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 1/22/2010 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P243V3281 Exp Date: 1/30/2010 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 3/23/2010 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P343V8321 Exp Date: 3/30/2010 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 5/22/2010 Additional Observations: Dose #: 3 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P853V2164 Exp Date: 8/30/2010 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 2/21/2011 Additional Observations: Dose #: 4 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P853V58532 Exp Date: 4/18/2011 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: rotavirus, unspecified formulation Administered: rotavirus, live, monovalent vaccine (CVX 119) ROTARIX (NDC 58160-0854-52)" Date Administered: 1/22/2010 Additional Observations: Dose #: 1 Doses in Series: 3 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: 1 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RV533 Exp Date: 2/15/2010 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: rotavirus, unspecified formulation Administered: rotavirus, live, monovalent vaccine (CVX 119) ROTARIX (NDC 58160-0854-52)" Date Administered: 3/23/2010 Additional Observations: Dose #: 2 Doses in Series: 3 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: 1 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RV932 Exp Date: 5/10/2011 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 9/25/2010 Additional Observations: Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D8043IN8734 Exp Date: 3/12/2011 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 10/27/2010 Additional Observations: Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D8043IN8734 Exp Date: 3/12/2011 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 10/2/2011 Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D9334IN9333 Exp Date: 5/22/2012 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 11/4/2012 Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D9553IN2243 Exp Date: 4/30/2012 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: influenza, unspecified formulation Administered: influenza, live, intranasal, quadrivalent (CVX 149) FluMist Quadrivalent (NDC 66019-0301-10)" Date Administered: Current Date Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Sandra Molina Entered By: Frank Smith Entering Organization: Oceanview Pediatrics Administered Amt: .2 mL Administering Provider: Sandra Molina Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901 Lot#: 8L4B3521 Exp Date: 7/15/2015 Manufacturer: MedImmune,LLC (MVX MED) Route: Nasal (NCIT C38284), Nasal (HL70162 NS) Site: Vaccine Group: Hep A, unspecified formulation Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) HAVRIX (NDC 58160-0825-52)" Date Administered: 11/23/2011 Additional Observations: Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RT33 Exp Date: 1/4/2012 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Deltoid (HL7 RD) Vaccine Group: Hep A, unspecified formulation Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) HAVRIX (NDC 58160-0825-52)" Date Administered: 5/23/2012 Additional Observations: Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RT48 Exp Date: 9/11/2012 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: MMR Administered: measles, mumps, rubella virus vaccine (CVX 03) MMR II (NDC 0006-4681-00)" Date Administered: 08/22/2011 Additional Observations: Dose #: Doses in Series: 2 Valid Dose: N Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 0853CC Exp Date: 12/15/2011 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Thigh (HL7 LT) Vaccine Group: MMR Administered: measles, mumps, rubella virus vaccine (CVX 03) MMR II (0006-4681-00)" Date Administered: 11/22/2014 Additional Observations: Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 0854FF Exp Date: 4/13/2015 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: MMR Administered: measles, mumps, rubella virus vaccine (CVX 03) MMR II (NDC 0006-4681-00)" Date Administered: 14 days PRIOR to day of TEST Additional Observations: Reaction (LOINC 31044-1)/fever of >40.5C (105F) within 48 hours of dose (CDCPHINVS VXC12) Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: Sandra Molina Entered By: Frank Smith Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: Sandra Molina Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901 Lot#: 0934GG Exp Date: 10/15/2016 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: Varicella Administered: Varicella vaccine (CVX 21) VarivaxI (NDC 0006-4827-00)" Date Administered: 12/15/2012 Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: J. Martinez Entered By: Carlos Herrera Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 2341BB Exp Date: 12/1/2013 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: Varicella Administered: Varicella vaccine (CVX 21) VarivaxI (NDC 0006-4827-00)" Date Administered: Date of Test Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: J. Martinez Entered By: Carlos Herrera Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 3452DD Exp Date: 12/1/2016 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Right Deltoid (HL7 RD)The Following Vaccine Forecast is displayed: Vaccine Group: IPV Due Date: 11/22/2013 Earliest Date to Give: 11/22/2013 Latest Date to Give: 11/22/2015 Overdue Date: 11/23/2015 Immunization Schedule: ACIP Vaccine Group: influenza, unspecified formulation Due Date: 10/21/2016 Earliest Date to Give: 9/1/2016 Latest Date to Give: 2/29/2017 Overdue Date: 3/1/3027 Immunization Schedule: ACIP |
| Notes for Testers |
|---|
No Note |
| Description |
|---|
| Querying the registry will consist of the vendor creating Z44 messages for Juan Marcel Gonzales to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
Juan Marcel Gonzales is selected as the patient and his record is opened in the EMR. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Juan Marcel Gonzales Initial Data Load completed. |
| Post Condition |
|---|
Juan Marcel Gonzales is the active working patient in the EMR. |
| Test Objectives |
|---|
Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother’s maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient’s information to external systems such as an immunization registry. |
| Evaluation Criteria |
|---|
Tester shall verify that the product can distinguish Juan Marcel Gonzales from similar sounding names using all of the pediatric demographics:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Juan Marcel Gonzales Initial Data Load is completed. |
| Post Condition |
|---|
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juan Marcel Gonzales. |
| Test Objectives |
|---|
Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry “on demand” (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother’s maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) – HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). |
| Evaluation Criteria |
|---|
Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission. Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied. |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juan Marcel Gonzales |
| Mother's Maiden Name | Morales |
| ID Number | 123456 |
| Date/Time of Birth | 03/04/2014 |
| Sex | Male |
| Patient Address | 4623 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1213 |
| Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Patient Name | Juan Marcel Gonzales |
| Mother's Maiden Name | Morales |
| ID Number | 123456 |
| Date/Time of Birth | 03/04/2014 |
| Sex | Male |
| Patient Address | 4623 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1213 |
| Birth Indicator | No |
| Birth Order |
| Description |
|---|
| The vendor will receive information back from the registry and show the ability to view and reconcile, and import the information returned by the registry (NOTE: the Z42 message will be provided either manually, or as part of the tool). This test will also look at the system's ability to view the forecast returned by the registry, and create a new forecast after reconciling the information. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
| The physician accesses the record for Juan Marcel Gonzales and: ??? Accepts the vaccines provided by the registry as this is a new patient and there are no prior vaccines recorded ??? Views the registry history including the second dose of Hepatitis B vaccine given late (at 2 years of age) and no history of a third dose; influenza vaccine was also not given since 2013 |
| Comments |
|---|
There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response. |
| Pre Condition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import.
|
| Post Condition |
|---|
| Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juan Marcel Gonzales) |
| Test Objectives |
|---|
Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. |
| Evaluation Criteria |
|---|
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. 2. The user imports returned vaccinations as follows:a. Vaccinations Imported: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 3/3/2014 hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 4/15/2014 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/15/2014diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 7/13/2014 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 9/16/2014 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 9/20/2015 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/14/2014 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 7/21/2014 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 9/27/2014 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/42015 poliovirus vaccine, inactivated (CVX 10) administered 5/14/2014 poliovirus vaccine, inactivated (CVX 10) administered 7/21/2014 poliovirus vaccine, inactivated (CVX 10) administered 10/15/2014 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/18/2014pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 7/21/2014 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 9/27/2014 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/4/2015 rotavirus, live, monovalent vaccine (CVX 119) administered 5/18/2014 rotavirus, live, monovalent vaccine (CVX 119) administered 7/21/2014 Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 9/27/2014Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/20/2015 hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 5/15/2015 measles, mumps, rubella, and varicella virus vaccine (CVX 94) administered 10/20/2015 |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Juan Marcel Gonzales Display Reconcile Update Immunization Information | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | Juan Marcel Gonzales | |
| Date of Birth | 03/04/2014 | |
| Sex | Male | |
| Address 1 | ||
| Street | 4623 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Anita Francesca Morales | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Shoreline Hospital | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | Hepatitis B | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/03/2014 | |
| Date/Time Administration-End | 03/03/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 325 Shorline Drive | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | Hepatitis B | |
| Refusal Reason | ||
| Date/Time Administration-Start | 04/15/2014 | |
| Date/Time Administration-End | 04/15/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/15/2014 | |
| Date/Time Administration-End | 05/15/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/13/2014 | |
| Date/Time Administration-End | 07/13/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/16/2014 | |
| Date/Time Administration-End | 09/16/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/20/2015 | |
| Date/Time Administration-End | 09/20/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/14/2014 | |
| Date/Time Administration-End | 05/14/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/21/2014 | |
| Date/Time Administration-End | 07/21/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/27/2014 | |
| Date/Time Administration-End | 09/27/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/04/2015 | |
| Date/Time Administration-End | 05/04/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | Polio (IPV) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/14/2014 | |
| Date/Time Administration-End | 05/14/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | MSanofi Pasteur Inc. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | Polio (IPV) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/21/2014 | |
| Date/Time Administration-End | 07/21/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | MSanofi Pasteur Inc. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Polio (IPV) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/15/2014 | |
| Date/Time Administration-End | 10/15/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | MSanofi Pasteur Inc. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/18/2014 | |
| Date/Time Administration-End | 05/18/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/21/2014 | |
| Date/Time Administration-End | 07/21/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/27/2014 | |
| Date/Time Administration-End | 09/27/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/04/2015 | |
| Date/Time Administration-End | 05/04/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | Rotavirus | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/18/2014 | |
| Date/Time Administration-End | 05/18/2014 | |
| Administered Amount | 1.0 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | Rotavirus | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/21/2014 | |
| Date/Time Administration-End | 07/21/2014 | |
| Administered Amount | 1.0 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Thigh Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/27/2014 | |
| Date/Time Administration-End | 09/27/2014 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/20/2015 | |
| Date/Time Administration-End | 10/20/2015 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | Hepatitis A | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/15/2015 | |
| Date/Time Administration-End | 05/15/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | MMRV | |
| Vaccine Administered | MMR and Varicella | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/20/2015 | |
| Date/Time Administration-End | 10/20/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep B, unspecified formulation | |
| Vaccine Due Date | 08/30/2014 | |
| Earliest Date to Give | 08/30/2014 | |
| Latest Date to Give | 08/30/2015 | |
| Date When Vaccine Overdue | 08/31/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | DTaP, unspecified formulation | |
| Vaccine Due Date | 03/02/2018 | |
| Earliest Date to Give | 03/02/2018 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 03/02/2018 | |
| Earliest Date to Give | 03/02/2018 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 09/01/2016 | |
| Earliest Date to Give | 08/30/2015 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | HepA | |
| Vaccine Due Date | 08/30/2015 | |
| Earliest Date to Give | 08/30/2015 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 03/02/2018 | |
| Earliest Date to Give | 03/02/2018 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 03/02/2018 | |
| Earliest Date to Give | 03/02/2018 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
| The physician accesses the record for Juan Marcel Gonzales and: • Views the vaccine forecast provided by the Immunization Registry |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| A Z44 query has been submitted to the Immunization Registry, a Z42 response is provided back to the EMR, and the vaccine forecast from the response is available in the EMR for viewing |
| Post Condition |
|---|
The vaccine forecast from the Immunization Registry is available for viewing in the EMR. |
| Test Objectives |
|---|
View Immunization Forecast: The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, ideal date, and maximum (latest) date for each vaccine included in the forecast. |
| Evaluation Criteria |
|---|
| 1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Juan Marcel Gonzales Display Reconcile Update Immunization Information | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | Juan Marcel Gonzales | |
| Date of Birth | 03/04/2014 | |
| Sex | Male | |
| Address 1 | ||
| Street | 4623 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Anita Francesca Morales | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Shoreline Hospital | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | Hepatitis B | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/03/2014 | |
| Date/Time Administration-End | 03/03/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 325 Shorline Drive | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | Hepatitis B | |
| Refusal Reason | ||
| Date/Time Administration-Start | 04/15/2014 | |
| Date/Time Administration-End | 04/15/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/15/2014 | |
| Date/Time Administration-End | 05/15/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/13/2014 | |
| Date/Time Administration-End | 07/13/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/16/2014 | |
| Date/Time Administration-End | 09/16/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/20/2015 | |
| Date/Time Administration-End | 09/20/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/14/2014 | |
| Date/Time Administration-End | 05/14/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/21/2014 | |
| Date/Time Administration-End | 07/21/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/27/2014 | |
| Date/Time Administration-End | 09/27/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/04/2015 | |
| Date/Time Administration-End | 05/04/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | Polio (IPV) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/14/2014 | |
| Date/Time Administration-End | 05/14/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | MSanofi Pasteur Inc. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | Polio (IPV) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/21/2014 | |
| Date/Time Administration-End | 07/21/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | MSanofi Pasteur Inc. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Polio (IPV) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/15/2014 | |
| Date/Time Administration-End | 10/15/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | MSanofi Pasteur Inc. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/18/2014 | |
| Date/Time Administration-End | 05/18/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/21/2014 | |
| Date/Time Administration-End | 07/21/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/27/2014 | |
| Date/Time Administration-End | 09/27/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/04/2015 | |
| Date/Time Administration-End | 05/04/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | Rotavirus | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/18/2014 | |
| Date/Time Administration-End | 05/18/2014 | |
| Administered Amount | 1.0 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | Rotavirus | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/21/2014 | |
| Date/Time Administration-End | 07/21/2014 | |
| Administered Amount | 1.0 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Thigh Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/27/2014 | |
| Date/Time Administration-End | 09/27/2014 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/20/2015 | |
| Date/Time Administration-End | 10/20/2015 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | Hepatitis A | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/15/2015 | |
| Date/Time Administration-End | 05/15/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | MMRV | |
| Vaccine Administered | MMR and Varicella | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/20/2015 | |
| Date/Time Administration-End | 10/20/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep B, unspecified formulation | |
| Vaccine Due Date | 08/30/2014 | |
| Earliest Date to Give | 08/30/2014 | |
| Latest Date to Give | 08/30/2015 | |
| Date When Vaccine Overdue | 08/31/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | DTaP, unspecified formulation | |
| Vaccine Due Date | 03/02/2018 | |
| Earliest Date to Give | 03/02/2018 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 03/02/2018 | |
| Earliest Date to Give | 03/02/2018 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 09/01/2016 | |
| Earliest Date to Give | 08/30/2015 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | HepA | |
| Vaccine Due Date | 08/30/2015 | |
| Earliest Date to Give | 08/30/2015 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 03/02/2018 | |
| Earliest Date to Give | 03/02/2018 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 03/02/2018 | |
| Earliest Date to Give | 03/02/2018 | |
| Latest Date to Give | 03/01/2020 | |
| Date When Vaccine Overdue | 03/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
| The physician accesses the record for Juan Marcel Gonzales and, once the vaccine history is reconciled in the EMR, the vaccine forecast is updated : • The provider views the updated vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods) |
| Comments |
|---|
The vaccine forecast may be imported from the Immunization Registry Vaccination History and Forecast (Z42) response, or it may be generated by EMR defined means. |
| Pre Condition |
|---|
| EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Juan Marcel Gonzales) |
| Post Condition |
|---|
| A vaccine forecast based upon the imported vaccine history is available to the user. |
| Test Objectives |
|---|
| View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient’s newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. |
| Evaluation Criteria |
|---|
1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history: Hep B Peds NOS due on 5/21/2012 DTaP due on 11/22/2015 MMR due on 11/22/2015 Varicella due on 11/22/2015 influenza, unspecified formulation due on Oct 22, 2015 or later
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
| This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
| The physician accesses the record for Juan Marcel Gonzales and: • Orders administration of Influenza vaccine (intranasal, live virus vaccine) • Receives notification the patient has asthma, a relative contraindication for intranasal influenza vaccine |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. |
| Post Condition |
|---|
User notified of history of contraindication tto nfluenza virus vaccine, live, attenuated, for intranasal use (CVX 111) |
| Test Objectives |
|---|
Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient’s current or historical diagnoses. |
| Evaluation Criteria | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following order information and Alert:
The Provider changes the order to:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
As indicated by the vaccine forecast, the third Hepatitis B is overdue, and is ordered. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. Vaccine forecast reviewed. |
| Post Condition |
|---|
Hepatitis B vaccine is ordered for the patient. |
| Test Objectives |
|---|
| Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines. |
| Evaluation Criteria | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following order information and Alert:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The fifth DTaP is ordered, and the provider is notified that the dose is too early. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. Vaccine forecast is available in the EMR. |
| Post Condition |
|---|
DTaP vaccine is ordered for the patient, and provider is notified that the dose is too early. |
| Test Objectives |
|---|
| Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required. Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines. |
| Evaluation Criteria | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following order information and Alert:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The nurse documents administration lot number for the Hepatitis B vaccine |
| Comments |
|---|
| Pre Condition |
|---|
Order is placed for Hepatitis B vaccine. |
| Post Condition |
|---|
The provider has been notified of the expired Hepatitis B vaccination lot. Documentation of a lot to be administered that is not expired is recorded in the EMR. |
| Test Objectives |
|---|
Notify of Vaccine Dose Expiration: The EHR or other clinical software system notifies the provider administering a vaccine if the dose chosen for administration is expired. |
| Evaluation Criteria | ||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| EMR Records the following order information and Alert:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
|
The nurse administers the the Hepatitis B vaccine
|
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| Order is placed for Hepatitis B vaccine. |
| Post Condition |
|---|
| The Hepatitis B vaccination is recorded in the EMR. |
| Test Objectives |
|---|
| Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following vaccine administration information:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The nurse documents administration for the inactivated influenza vaccine from a VFC source |
| Comments |
|---|
This step covers data quality checking as an informative aspect of vaccine administration |
| Pre Condition |
|---|
Order is placed for inactivated influenza vaccine. |
| Post Condition |
|---|
The user is notified of vaccine dose ineligibility. |
| Test Objectives |
|---|
Notify of Vaccine Dose Ineligibility: The EHR or other clinical software system provides a method for alerting a provider if a vaccine is selected for a patient who is not eligible for the inventory item selected. |
| Evaluation Criteria | ||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
The provider documents a VFC lot to be administered in the EMR. Once notified that the patient is not eligible for the VFC, the a non-VFC lot is selected.
The Provider selects a non-VFC Lot:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
|
The nurse administers the inactivated influenza vaccine
|
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| Order is placed for inactivated influenza vaccine. |
| Post Condition |
|---|
| The inactivated influenza vaccine administration is recorded in the EMR. |
| Test Objectives |
|---|
| Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following vaccine administration information:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
| Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
The Report must include all newly administered vaccines in any order. The report may include the information imported from the IIS. |
| Pre Condition |
|---|
The vaccines for the visit have been administered. |
| Post Condition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juan Marcel Gonzales |
| Mother's Maiden Name | Anita Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 03/04/2014 11:00 |
| Administrative Sex | Male |
| Patient Address | 4623 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1213 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 03/04/2014 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 03/04/2014 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Manuel Marcel Gonzales |
| Relationship | Father |
| Address | 4623 Standish Way Stamford CT 06903 |
| Phone Number | (203)555-1213 |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 03/03/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6332FK34 |
| Substance Expiration Date | 12/14/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 04/15/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6352FK2 |
| Substance Expiration Date | 10/01/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6332FK26 |
| Substance Expiration Date | 10/31/2016 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 02/02/2012 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 05/15/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2342 |
| Substance Expiration Date | 11/30/2015 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 07/13/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2434 |
| Substance Expiration Date | 09/04/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 09/16/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 12/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 09/20/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 03/01/2015 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 05/14/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M54K9255 |
| Substance Expiration Date | 03/24/2015 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 07/21/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M55K3343 |
| Substance Expiration Date | 10/30/2014 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 09/27/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M75K4577 |
| Substance Expiration Date | 05/23/2014 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 05/04/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M53K5535 |
| Substance Expiration Date | 10/14/2015 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Polio (IPV) |
| Date/Time Start of Administration | 05/14/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV2444 |
| Substance Expiration Date | 10/03/2014 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Polio (IPV) |
| Date/Time Start of Administration | 07/21/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 03/23/2015 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Polio (IPV) |
| Date/Time Start of Administration | 10/15/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 02/22/2015 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 05/18/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P243V3321 |
| Substance Expiration Date | 01/30/2015 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 07/21/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P343V8445 |
| Substance Expiration Date | 03/30/2015 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 09/27/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V2175 |
| Substance Expiration Date | 08/30/2015 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 05/04/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V58544 |
| Substance Expiration Date | 01/18/2015 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Rotavirus |
| Date/Time Start of Administration | 05/18/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV543 |
| Substance Expiration Date | 10/29/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Rotavirus |
| Date/Time Start of Administration | 07/21/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV933 |
| Substance Expiration Date | 05/10/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Thigh Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza |
| Date/Time Start of Administration | 09/27/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8738 |
| Substance Expiration Date | 03/12/2015 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza |
| Date/Time Start of Administration | 10/20/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8798 |
| Substance Expiration Date | 05/22/2016 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | D8043IN8855 |
| Substance Expiration Date | 10/31/2016 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis A |
| Date/Time Start of Administration | 05/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RT35 |
| Substance Expiration Date | 01/04/2016 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis A |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6359RT47 |
| Substance Expiration Date | 10/31/2016 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Vaccine | MMR and Varicella |
| Date/Time Start of Administration | 10/20/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7W27V7632 |
| Substance Expiration Date | 12/15/2016 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Patient Name | Juan Marcel Gonzales |
| Mother's Maiden Name | Anita Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 03/04/2014 11:00 |
| Administrative Sex | Male |
| Patient Address | 4623 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1213 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 03/04/2014 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 03/04/2014 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Manuel Marcel Gonzales |
| Relationship | Father |
| Address | 4623 Standish Way Stamford CT 06903 |
| Phone Number | (203)555-1213 |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 03/03/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6332FK34 |
| Substance Expiration Date | 12/14/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 04/15/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6352FK2 |
| Substance Expiration Date | 10/01/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6332FK26 |
| Substance Expiration Date | 10/31/2016 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 02/02/2012 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 05/15/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2342 |
| Substance Expiration Date | 11/30/2015 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 07/13/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2434 |
| Substance Expiration Date | 09/04/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 09/16/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 12/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 09/20/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 03/01/2015 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 05/14/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M54K9255 |
| Substance Expiration Date | 03/24/2015 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 07/21/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M55K3343 |
| Substance Expiration Date | 10/30/2014 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 09/27/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M75K4577 |
| Substance Expiration Date | 05/23/2014 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 05/04/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M53K5535 |
| Substance Expiration Date | 10/14/2015 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Polio (IPV) |
| Date/Time Start of Administration | 05/14/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV2444 |
| Substance Expiration Date | 10/03/2014 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Polio (IPV) |
| Date/Time Start of Administration | 07/21/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 03/23/2015 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Polio (IPV) |
| Date/Time Start of Administration | 10/15/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 02/22/2015 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 05/18/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P243V3321 |
| Substance Expiration Date | 01/30/2015 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 07/21/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P343V8445 |
| Substance Expiration Date | 03/30/2015 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 09/27/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V2175 |
| Substance Expiration Date | 08/30/2015 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 05/04/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V58544 |
| Substance Expiration Date | 01/18/2015 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Rotavirus |
| Date/Time Start of Administration | 05/18/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV543 |
| Substance Expiration Date | 10/29/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Rotavirus |
| Date/Time Start of Administration | 07/21/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV933 |
| Substance Expiration Date | 05/10/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Thigh Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza |
| Date/Time Start of Administration | 09/27/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8738 |
| Substance Expiration Date | 03/12/2015 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza |
| Date/Time Start of Administration | 10/20/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8798 |
| Substance Expiration Date | 05/22/2016 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | D8043IN8855 |
| Substance Expiration Date | 10/31/2016 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis A |
| Date/Time Start of Administration | 05/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RT35 |
| Substance Expiration Date | 01/04/2016 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis A |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6359RT47 |
| Substance Expiration Date | 10/31/2016 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Vaccine | MMR and Varicella |
| Date/Time Start of Administration | 10/20/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7W27V7632 |
| Substance Expiration Date | 12/15/2016 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Description |
|---|
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| Post Condition |
|---|
| The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| Post Condition |
|---|
| The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
The following patient demographics are displayed: Patient Identifier Number: Vendor Assigned Patient Identifier Type Code: Vendor Assigned Patient Name: Juan Marcel Gonzales Date/Time of Birth: 3/4/2014 11:00am Sex: Male Patient Address: 4623 Standish Way, Stamford, CT 06903 Multiple Birth: N Birth Order: NA The following Vaccination History is displayed: Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 3/4/2014 Additional Observations: Dose #: 1 Doses in Series: 3 Valid Dose: Y Ordering Provider: Jane Carter Entered By: Lisa Sirtis Entering Organization: Shoreline Hospital Administered Amt: .05 mL Administering Provider: Jane Carter Administered at Location: 325 Shorline Drive, Stamford Connecticut 06901 Lot#: 6332FK34 Exp Date: 12/14/2014 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 4/15/2014 Additional Observations: Dose #: 2 Doses in Series: 3 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: 6352FK2 Exp Date: 10/1/2015 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: Current Date Additional Observations: Dose #: 3 Doses in Series: 3 Valid Dose: Y Ordering Provider: Sandra Molina Entered By: Frank Smith Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: Sandra Molina Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901 Lot#: 6332FK26 Exp Date: 10/31/2016 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL70162 LD) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 5/15/2014 Additional Observations: Dose #: 1 Doses in Series: 5 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D409QS2342 Exp Date: 11/30/2015 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 7/13/2014 Additional Observations: Dose #: 2 Doses in Series: 5 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D409QS2434 Exp Date: 9/4/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 916/2014 Additional Observations: Dose #: 3 Doses in Series: 5 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D409QS3256 Exp Date: 12/1/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 9/20/2015 Additional Observations: Dose #: 3 Doses in Series: 5 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D409QS3256 Exp Date: 3/1/2015 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 5/14/2014 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: 7M54K9255 Exp Date: 3/24/2015 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 7/21/2014 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: 7M55K3343 Exp Date: 10/30/2014 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 9/27/2014 Additional Observations: Dose #: 3 Doses in Series: 4 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: 7M75K4577 Exp Date: 5/23/2014 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 5/4/2015 Additional Observations: Dose #: 4 Doses in Series: 4 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: 7M53K5535 Exp Date: 10/14/2015 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55)" Date Administered: 5/14/2014 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D333PV2444 Exp Date: 10/4/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55)" Date Administered: 7/21/2014 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D333PV4343 Exp Date: 3/23/2015 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55) Date Administered: 10/15/2014 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D335PV9654 Exp Date: 2/22/2015 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 5/18/2014 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: P243V3321 Exp Date: 1/30/2015 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 7/21/2014 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: P343V8445 Exp Date: 3/30/2015 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 9/27/2014 Additional Observations: Dose #: 3 Doses in Series: 4 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: P853V2175 Exp Date: 8/30/2015 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 5/4/2015 Additional Observations: Dose #: 4 Doses in Series: 4 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: P853V58544 Exp Date: 10/18/2015 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: rotavirus, unspecified formulation Administered: rotavirus, live, monovalent vaccine (CVX 119) ROTARIX (NDC 58160-0854-52)" Date Administered: 5/18/2014 Additional Observations: Dose #: 1 Doses in Series: 3 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: 1 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: 6359RV533 Exp Date: 10/29/2014 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: rotavirus, unspecified formulation Administered: rotavirus, live, monovalent vaccine (CVX 119) ROTARIX (NDC 58160-0854-52)" Date Administered: 7/21/2014 Additional Observations: Dose #: 2 Doses in Series: 3 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: 1 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: 6359RV932 Exp Date: 5/10/2015 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 9/27/2014 Additional Observations: Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D8043IN8734 Exp Date: 3/12/2015 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 10/20/2015 Additional Observations: Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D8043IN8798 Exp Date: 5/22/2016 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: Current Date Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Sandra Molina Entered By: Frank Smith Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: Sandra Molina Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901 Lot#: D8043IN8855 Exp Date:10/31/2016 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: Hep A, unspecified formulation Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) HAVRIX (NDC 58160-0825-52)" Date Administered: 5/15/2015 Additional Observations: Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: 6359RT35 Exp Date: 1/4/2016 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Deltoid (HL7 RD) Vaccine Group: Hep A, unspecified formulation Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) HAVRIX (NDC 58160-0825-52)" Date Administered: Current Date Additional Observations: Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: 6359RT47 Exp Date: 10/31/2016 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: MMRV Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94) ProQuad (NDC 00006-4999-00)" Date Administered: 10/20/2015 Additional Observations: Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: 7W27V7632 Exp Date: 12/15/2016 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Thigh (HL7 LT) The Following Vaccine Forecast is displayed: Vaccine Group: HepB Due Date: 11/22/2015 Earliest Date to Give: 08/30/2014 Latest Date to Give: 08/30/2015 Overdue Date: 08/31/2015 Immunization Schedule: ACIP Vaccine Group: Dtap Due Date: 3/3/2018 Earliest Date to Give: 3/3/2018 Latest Date to Give: 3/3/2020 Overdue Date: 3/4/2020 Immunization Schedule: ACIP Vaccine Group: IPV Due Date: 3/3/2018 Earliest Date to Give: 3/3/2018 Latest Date to Give: 3/3/2020 Overdue Date: 3/4/2020 Immunization Schedule: ACIP Vaccine Group: Influenza Due Date: 9/1/2016 Earliest Date to Give: 9/1/2016 Latest Date to Give: 1/31/2017 Overdue Date: 2/1/2017 Immunization Schedule: ACIP Vaccine Group: HepA Due Date: 11/22/2015 Earliest Date to Give: 8/30/2015 Immunization Schedule: ACIPVaccine Group: MMR Due Date: 3/2/2018 Earliest Date to Give: 3/2/2018 Latest Date to Give: 3/1/2020 Overdue Date: 3/2/2020 Immunization Schedule: ACIP Vaccine Group: Varicella Due Date: 3/2/2018 Earliest Date to Give: 3/2/2018 Latest Date to Give: 3/1/2020 Overdue Date: 3/2/2020 Immunization Schedule: ACIP
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
| Querying the registry will consist of the vendor creating Z44 messages for Mariela Gonzales Morales to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
Mariela Gonzales Morales is selected as the patient and her record is opened in the EMR. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Mariela Gonzales Morales Initial Data Load completed. |
| Post Condition |
|---|
Mariela Gonzales Morales is the active working patient in the EMR. |
| Test Objectives |
|---|
Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother’s maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient’s information to external systems such as an immunization registry. |
| Evaluation Criteria |
|---|
Tester shall verify that the product can distinguish Mariela Gonzales Morales from similar sounding names and her twin using all of the pediatric demographics:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Mariela Gonzales Morales Initial Data Load is completed. |
| Post Condition |
|---|
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Mariela Gonzales Morales. |
| Test Objectives |
|---|
Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry “on demand” (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother’s maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) – HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). |
| Evaluation Criteria |
|---|
Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission. Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied. |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Mariela Gonzales Morales |
| Mother's Maiden Name | Gonzales |
| ID Number | 123456 |
| Date/Time of Birth | 10/01/2015 |
| Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1214 |
| Birth Indicator | Yes |
| Birth Order | 1 |
| Element | Data |
|---|---|
| Patient Name | Mariela Gonzales Morales |
| Mother's Maiden Name | Gonzales |
| ID Number | 123456 |
| Date/Time of Birth | 10/01/2015 |
| Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1214 |
| Birth Indicator | Yes |
| Birth Order | 1 |
| Description |
|---|
| The vendor will receive information back from the registry and show the ability to view and reconcile, and import the information returned by the registry (NOTE: the Z42 message will be provided either manually, or as part of the tool). This test will also look at the system's ability to view the forecast returned by the registry, and create a new forecast after reconciling the information. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
| The physician accesses the record for Mariela Gonzales Morales and: • Accepts the single vaccine in the registry record into the EHR history |
| Comments |
|---|
| There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response. |
| Pre Condition |
|---|
| A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import. |
| Post Condition |
|---|
| Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Mariela Gonzales Morales) |
| Test Objectives |
|---|
| Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. |
| Evaluation Criteria |
|---|
| 1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. 2. The user imports returned vaccinations as follows:
a. Vaccinations Imported: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 3/30/2015 |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | BG2 Morales |
| Mother's Maiden Name | Joanna Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 03/30/2015 11:00 |
| Administrative Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1212 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 10/01/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Susan Pike |
| Substance Lot Number | 6332FL432 |
| Substance Expiration Date | 12/14/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Stamford Regional Hospital |
| Entered By | Susan Pike |
| Ordered By | Justin Parker |
| Element | Data |
|---|---|
| vaccine type | Hep B Peds NOS |
| dose number in series | |
| number of doses in series | |
| Immunization Schedule used | ACIP |
| Dose validity | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hep B, unspecified formulation |
| Earliest date to give | 10/31/2015 |
| Date vaccination due | 10/31/2015 |
| Latest date next dose may be given | 11/30/2015 |
| Date dose is overdue | 12/01/2015 |
| Immunization Schedule used | ACIP |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | DTaP, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hib |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | IPV |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Pneumococcal Conjugate, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | rotavirus, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | influenza, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 08/31/2016 |
| Date vaccination due | 08/31/2016 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hep A, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 09/30/2017 |
| Date dose is overdue | 10/01/2017 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | MMR |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 12/29/2016 |
| Date dose is overdue | 12/30/2016 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Varicella |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 12/29/2016 |
| Date dose is overdue | 12/30/2016 |
| dose number in series | |
| Element | Data |
|---|---|
| Patient Name | BG2 Morales |
| Mother's Maiden Name | Joanna Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 03/30/2015 11:00 |
| Administrative Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1212 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 10/01/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Susan Pike |
| Substance Lot Number | 6332FL432 |
| Substance Expiration Date | 12/14/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Stamford Regional Hospital |
| Entered By | Susan Pike |
| Ordered By | Justin Parker |
| Element | Data |
|---|---|
| vaccine type | Hep B Peds NOS |
| dose number in series | |
| number of doses in series | |
| Immunization Schedule used | ACIP |
| Dose validity | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hep B, unspecified formulation |
| Earliest date to give | 10/31/2015 |
| Date vaccination due | 10/31/2015 |
| Latest date next dose may be given | 11/30/2015 |
| Date dose is overdue | 12/01/2015 |
| Immunization Schedule used | ACIP |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | DTaP, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hib |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | IPV |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Pneumococcal Conjugate, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | rotavirus, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | influenza, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 08/31/2016 |
| Date vaccination due | 08/31/2016 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hep A, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 09/30/2017 |
| Date dose is overdue | 10/01/2017 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | MMR |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 12/29/2016 |
| Date dose is overdue | 12/30/2016 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Varicella |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 12/29/2016 |
| Date dose is overdue | 12/30/2016 |
| dose number in series | |
| Description |
|---|
| The physician accesses the record for Mariela Gonzales Morales and: • Views the vaccine forecast provided by the Immunization Registry |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| A Z44 query has been submitted to the Immunization Registry, a Z42 response is provided back to the EMR, and the vaccine forecast from the response is available in the EMR for viewing |
| Post Condition |
|---|
| The vaccine forecast from the Immunization Registry is available for viewing in the EMR. |
| Test Objectives |
|---|
| View Immunization Forecast: The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, ideal date, and maximum (latest) date for each vaccine included in the forecast. |
| Evaluation Criteria |
|---|
| The EMR displays the information returned from the Immunization Registry, including: 1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history: Hep B Peds NOS due on 6/29/2015 DTaP due on 7/29/2015 Hib due on 7/29/2015 Pneumococcal conjugate due on 7/29/2015 Rotavirus due on 7/29/2015 HepA due on 5/29/2016 MMR due on 5/29/2016 Varicella due on 5/29/2016 influenza, unspecified formulation due on Nov 26, 2015 or later |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | BG2 Morales |
| Mother's Maiden Name | Joanna Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 03/30/2015 11:00 |
| Administrative Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1212 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 10/01/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Susan Pike |
| Substance Lot Number | 6332FL432 |
| Substance Expiration Date | 12/14/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Stamford Regional Hospital |
| Entered By | Susan Pike |
| Ordered By | Justin Parker |
| Element | Data |
|---|---|
| vaccine type | Hep B Peds NOS |
| dose number in series | |
| number of doses in series | |
| Immunization Schedule used | ACIP |
| Dose validity | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hep B, unspecified formulation |
| Earliest date to give | 10/31/2015 |
| Date vaccination due | 10/31/2015 |
| Latest date next dose may be given | 11/30/2015 |
| Date dose is overdue | 12/01/2015 |
| Immunization Schedule used | ACIP |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | DTaP, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hib |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | IPV |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Pneumococcal Conjugate, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | rotavirus, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | influenza, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 08/31/2016 |
| Date vaccination due | 08/31/2016 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hep A, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 09/30/2017 |
| Date dose is overdue | 10/01/2017 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | MMR |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 12/29/2016 |
| Date dose is overdue | 12/30/2016 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Varicella |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 12/29/2016 |
| Date dose is overdue | 12/30/2016 |
| dose number in series | |
| Element | Data |
|---|---|
| Patient Name | BG2 Morales |
| Mother's Maiden Name | Joanna Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 03/30/2015 11:00 |
| Administrative Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1212 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 10/01/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Susan Pike |
| Substance Lot Number | 6332FL432 |
| Substance Expiration Date | 12/14/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Stamford Regional Hospital |
| Entered By | Susan Pike |
| Ordered By | Justin Parker |
| Element | Data |
|---|---|
| vaccine type | Hep B Peds NOS |
| dose number in series | |
| number of doses in series | |
| Immunization Schedule used | ACIP |
| Dose validity | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hep B, unspecified formulation |
| Earliest date to give | 10/31/2015 |
| Date vaccination due | 10/31/2015 |
| Latest date next dose may be given | 11/30/2015 |
| Date dose is overdue | 12/01/2015 |
| Immunization Schedule used | ACIP |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | DTaP, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hib |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | IPV |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Pneumococcal Conjugate, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | rotavirus, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 11/30/2015 |
| Date vaccination due | 11/30/2015 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | influenza, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 08/31/2016 |
| Date vaccination due | 08/31/2016 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Hep A, unspecified formulation |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 09/30/2017 |
| Date dose is overdue | 10/01/2017 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | MMR |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 12/29/2016 |
| Date dose is overdue | 12/30/2016 |
| dose number in series | |
| Element | Data |
|---|---|
| Administered Vaccine | no vaccine admin |
| Date/Time Start of Administration | 06/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | |
| Route | |
| Administration Site | |
| Entering Organization | StateIIS |
| Entered By | Myron Clerk |
| Ordered By |
| Element | Data |
|---|---|
| vaccine type | Varicella |
| Immunization Schedule used | ACIP |
| Earliest date to give | 09/30/2016 |
| Date vaccination due | 09/30/2016 |
| Latest date next dose may be given | 12/29/2016 |
| Date dose is overdue | 12/30/2016 |
| dose number in series | |
| Description |
|---|
| The physician accesses the record for Mariela Gonzales Morales and: • Views the vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods) |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Mariela Gonzales Morales) |
| Post Condition |
|---|
| A vaccine forecast based upon the imported vaccine history is available to the user. |
| Test Objectives |
|---|
| View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient’s newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. |
| Evaluation Criteria |
|---|
1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history: Hep B Peds NOS due on 6/29/2015 DTaP due on 7/29/2015 Hib due on 7/29/2015 Pneumococcal conjugate due on 7/29/2015 Rotavirus due on 7/29/2015 HepA due on 5/29/2016 MMR due on 5/29/2016 Varicella due on 5/29/2016 influenza, unspecified formulation due on Nov 26, 2015 or later |
| Notes for Testers |
|---|
No Note |
| Description |
|---|
| This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
The triage nurse enters basic information on Mariela Gonzales Morales – she has a fever (Temperature of 100.8o F). |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
The EMR has recorded all of the pediatric demographic in the record created for Mariela Gonzales Morales. |
| Post Condition |
|---|
The clinical record for Mariela Gonzales Morales indicates that she currently has a fever (temperature 100.8oF).. |
| Test Objectives |
|---|
Supporting data for documenting contraindications (it could also trigger an alert as a locally configured alert rule): Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient’s current or historical diagnoses. |
| Evaluation Criteria | ||||||||
|---|---|---|---|---|---|---|---|---|
Evaluation Criteria: Vendor successfully records all clinical data provided with all required attributes indicated by [Y]:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The physician accesses the record for Mariela Gonzales Morales and: |
| Comments |
|---|
No Comment |
| Pre Condition |
|---|
| Prior Immunization History loaded and reconciled from the Immunization Registry. Vaccine forecast is available in the EMR indicating 5 vaccines are due: Hepatitis B, DTaP, Hib, Pneumococcal conjugate (PCV13) and Rotavirus |
| Post Condition |
|---|
Vaccine deferral is recorded indicating the medical reason of low grade fever |
| Test Objectives |
|---|
Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed. |
| Evaluation Criteria | ||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following vaccine administration information:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
| Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes the vaccine deferrals. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
The Report must include all vaccine deferrals recorded in the EMR in any order. The report may include the information imported from the IIS |
| Pre Condition |
|---|
The vaccines for the visit have been administered. |
| Post Condition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. The message must contain all deferrals recorded in the EMR. Current Date is expected for the Non-Administration date and deferral date. |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Mariela Gonzales Morales |
| Mother's Maiden Name | Joanna Gonzales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 10/01/2015 11:15 |
| Administrative Sex | Female |
| Patient Address 1 | 3321 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1214 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Gonzales Morales |
| Relationship | Mother |
| Address | 4623 Standish Way Stamford CT 06903 |
| Phone Number | (203)555-1213 |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 10/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 12/01/2015 |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP, unspecified formulation |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 12/01/2015 |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 12/01/2015 |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal Conjugate, unspecified formulation |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 12/01/2015 |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, unspecified formulation |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 12/01/2015 |
| Element | Data |
|---|---|
| Patient Name | Mariela Gonzales Morales |
| Mother's Maiden Name | Joanna Gonzales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 10/01/2015 11:15 |
| Administrative Sex | Female |
| Patient Address 1 | 3321 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1214 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Gonzales Morales |
| Relationship | Mother |
| Address | 4623 Standish Way Stamford CT 06903 |
| Phone Number | (203)555-1213 |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 10/01/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 12/01/2015 |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP, unspecified formulation |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 12/01/2015 |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 12/01/2015 |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal Conjugate, unspecified formulation |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 12/01/2015 |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, unspecified formulation |
| Date/Time Start of Administration | 10/31/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 12/01/2015 |
| Description |
|---|
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| Post Condition |
|---|
| The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| Post Condition |
|---|
| The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
The following patient demographics are displayed: Patient Identifier Number: Vendor Supplied Patient Identifier Type Code: Vendor Supplied Patient Name: Mariela Gonzales Morales Date/Time of Birth: 10/1/2015 11:00am Sex: Female Patient Address: 3321 Standish Way, Stamford, CT 06903 Multiple Birth: Y Birth Order: 1 The following Vaccination History is displayed: Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 10/1/2015 Additional Observations: Dose #: 1 Doses in Series: 3 Valid Dose: Y Ordering Provider: Jane Carter Entered By: Lisa Sirtis Entering Organization: Shoreline Hospital Administered Amt: .05 mL Administering Provider: Jane Carter Administered at Location: 325 Shorline Drive, Stamford Connecticut 06901 Lot#: 6332FL432 Exp Date: 12/14/2015 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) The Following Vaccine Forecast is displayed: Vaccine Group: Hep B Peds NOS Due Date: 6/29/2015 Earliest Date to Give:10/31/2015 Latest Date to Give: 11/30/2015 Overdue Date: 12/1/2015 Immunization Schedule: ACIP Vaccine Group: DTaP Due Date: 11/30/2015 Earliest Date to Give: 11/30/2015 Latest Date to Give: Overdue Date: Immunization Schedule: ACIP Vaccine Group: Hib Due Date: 11/30/2015 Earliest Date to Give: 11/30/2015 Latest Date to Give:Overdue Date: Immunization Schedule: ACIP Vaccine Group: IPV Due Date: 11/30/2015 Earliest Date to Give: 11/30/2015 Latest Date to Give:Overdue Date: Immunization Schedule: ACIP Vaccine Group: Pneumococcal conjugate Due Date: 11/30/2015 Earliest Date to Give: 11/30/2015 Latest Date to Give:Overdue Date: Immunization Schedule: ACIP Vaccine Group: Rotavirus Due Date: 11/30/2015 Earliest Date to Give: 11/30/2015 Latest Date to Give:Overdue Date: Immunization Schedule: ACIP Vaccine Group: Influenza Due Date: Nov 26, 2015 or later later Earliest Date to Give: 08/31/2016 Latest Date to Give: Overdue Date: Immunization Schedule: ACIP Vaccine Group: HepA Due Date: 5/29/2016 Earliest Date to Give: 9/30/2016 Latest Date to Give: 9/30/2017 Overdue Date: 10/1/2017 Immunization Schedule: ACIP Vaccine Group: MMR Due Date: 9/30/2016 Earliest Date to Give: 9/30/2016 Latest Date to Give: 12/29/2016 Overdue Date: 12/30/2016 Immunization Schedule: ACIP Vaccine Group: Varicella Due Date: 9/30/2016 Earliest Date to Give: 9/30/2016 Latest Date to Give: 12/29/2016 Overdue Date: 12/30/2016 Immunization Schedule: ACIP |
| Notes for Testers |
|---|
No Note |
| Description |
|---|
| Querying the registry will consist of the vendor creating Z44 messages for Juana Maria Gonzales Morales to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
Juana Maria Gonzales Morales is selected as the patient and her record is opened in the EMR. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Juana Maria Gonzales Morales Initial Data Load completed. |
| Post Condition |
|---|
Juana Maria Gonzales Morales is the active working patient in the EMR. |
| Test Objectives |
|---|
Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother’s maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient’s information to external systems such as an immunization registry. |
| Evaluation Criteria |
|---|
Tester shall verify that the product can distinguish Juana Maria Gonzales Morales from similar sounding names and her twin using all of the pediatric demographics:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Juana Maria Gonzales Morales Initial Data Load is completed. |
| Post Condition |
|---|
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Maria Gonzales Morales. |
| Test Objectives |
|---|
Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry “on demand” (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother’s maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) – HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). |
| Evaluation Criteria |
|---|
Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission. Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied. |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juana Maria Gonzales Morales |
| Mother's Maiden Name | Gonzales |
| ID Number | 123456 |
| Date/Time of Birth | 10/01/2015 |
| Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1214 |
| Birth Indicator | Yes |
| Birth Order | 2 |
| Element | Data |
|---|---|
| Patient Name | Juana Maria Gonzales Morales |
| Mother's Maiden Name | Gonzales |
| ID Number | 123456 |
| Date/Time of Birth | 10/01/2015 |
| Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1214 |
| Birth Indicator | Yes |
| Birth Order | 2 |
| Description |
|---|
| The vendor will receive information back from the registry and show the ability to view and reconcile, and import the information returned by the registry (NOTE: the Z42 message will be provided either manually, or as part of the tool). This test will also look at the system's ability to view the forecast returned by the registry, and create a new forecast after reconciling the information. |
| Comments |
|---|
| No Comments |
| Pre Condition |
|---|
| No PreCondition |
| Post Condition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes for Testers |
|---|
| No Note |
| Description |
|---|
| The physician accesses the record for Juana Maria Gonzales Morales and: • Accepts the single vaccine in the registry record into the EHR history |
| Comments |
|---|
| There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response. |
| Pre Condition |
|---|
| A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import. |
| Post Condition |
|---|
| Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Maria Gonzales Morales) |
| Test Objectives |
|---|
| Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. |
| Evaluation Criteria |
|---|
| 1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. 2. The user imports returned vaccinations as follows:
a. Vaccinations Imported: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 3/30/2015 |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Juana Maria Gonzales Morales Display Reconcile Update Immunization Information | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | BG2 Gonzales | |
| Date of Birth | 10/01/2015 | |
| Sex | Female | |
| Address 1 | ||
| Street | 3321 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Joanna Gonzales Morales | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Stamford Regional Hospital | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | Hepatitis B | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/01/2015 | |
| Date/Time Administration-End | 10/01/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | Susan Pike | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 15 Atlantic Avenue | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep B, unspecified formulation | |
| Vaccine Due Date | 10/31/2015 | |
| Earliest Date to Give | 10/31/2015 | |
| Latest Date to Give | 11/30/2015 | |
| Date When Vaccine Overdue | 12/01/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | DTaP, unspecified formulation | |
| Vaccine Due Date | 11/30/2015 | |
| Earliest Date to Give | 11/30/2015 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Hib | |
| Vaccine Due Date | 11/30/2015 | |
| Earliest Date to Give | 11/30/2015 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 11/30/2015 | |
| Earliest Date to Give | 11/30/2015 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Pneumococcal Conjugate, unspecified formulation | |
| Vaccine Due Date | 11/30/2015 | |
| Earliest Date to Give | 11/30/2015 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Due Date | 11/30/2015 | |
| Earliest Date to Give | 11/30/2015 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 08/31/2016 | |
| Earliest Date to Give | 08/31/2016 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Due Date | 09/30/2016 | |
| Earliest Date to Give | 09/30/2016 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 09/30/2016 | |
| Earliest Date to Give | 09/30/2016 | |
| Latest Date to Give | 12/29/2016 | |
| Date When Vaccine Overdue | 12/30/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 09/30/2016 | |
| Earliest Date to Give | 09/30/2016 | |
| Latest Date to Give | 12/29/2016 | |
| Date When Vaccine Overdue | 12/30/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
| The physician accesses the record for Juana Maria Gonzales Morales and: • Views the vaccine forecast provided by the Immunization Registry |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| A Z44 query has been submitted to the Immunization Registry, a Z42 response is provided back to the EMR, and the vaccine forecast from the response is available in the EMR for viewing |
| Post Condition |
|---|
| The vaccine forecast from the Immunization Registry is available for viewing in the EMR. |
| Test Objectives |
|---|
| View Immunization Forecast: The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, ideal date, and maximum (latest) date for each vaccine included in the forecast. |
| Evaluation Criteria |
|---|
| 1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. |
| Notes for Testers |
|---|
No Note |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Juana Maria Gonzales Morales Display Reconcile Update Immunization Information | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | BG2 Gonzales | |
| Date of Birth | 10/01/2015 | |
| Sex | Female | |
| Address 1 | ||
| Street | 3321 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Joanna Gonzales Morales | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Stamford Regional Hospital | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | Hepatitis B | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/01/2015 | |
| Date/Time Administration-End | 10/01/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | Susan Pike | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 15 Atlantic Avenue | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep B, unspecified formulation | |
| Vaccine Due Date | 10/31/2015 | |
| Earliest Date to Give | 10/31/2015 | |
| Latest Date to Give | 11/30/2015 | |
| Date When Vaccine Overdue | 12/01/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | DTaP, unspecified formulation | |
| Vaccine Due Date | 11/30/2015 | |
| Earliest Date to Give | 11/30/2015 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Hib | |
| Vaccine Due Date | 11/30/2015 | |
| Earliest Date to Give | 11/30/2015 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 11/30/2015 | |
| Earliest Date to Give | 11/30/2015 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Pneumococcal Conjugate, unspecified formulation | |
| Vaccine Due Date | 11/30/2015 | |
| Earliest Date to Give | 11/30/2015 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Due Date | 11/30/2015 | |
| Earliest Date to Give | 11/30/2015 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 08/31/2016 | |
| Earliest Date to Give | 08/31/2016 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Due Date | 09/30/2016 | |
| Earliest Date to Give | 09/30/2016 | |
| Latest Date to Give | 09/30/2017 | |
| Date When Vaccine Overdue | 10/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 09/30/2016 | |
| Earliest Date to Give | 09/30/2016 | |
| Latest Date to Give | 12/29/2016 | |
| Date When Vaccine Overdue | 12/30/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 09/30/2016 | |
| Earliest Date to Give | 09/30/2016 | |
| Latest Date to Give | 12/29/2016 | |
| Date When Vaccine Overdue | 12/30/2016 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
| The physician accesses the record for Juana Maria Gonzales Morales and: • Views the vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods) |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
| EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Juana Maria Gonzales Morales) |
| Post Condition |
|---|
| A vaccine forecast based upon the imported vaccine history is available to the user. |
| Test Objectives |
|---|
| View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient’s newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. |
| Evaluation Criteria |
|---|
1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history: Hep B Peds NOS due on 6/29/2015 DTaP due on 7/29/2015 Hib due on 7/29/2015 Pneumococcal conjugate due on 7/29/2015 Rotavirus due on 7/29/2015 HepA due on 5/29/2016 MMR due on 5/29/2016 Varicella due on 5/29/2016 |
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The provider periodically uses the EMR to identify the cohort of patients that are overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR. |
| Post Condition |
|---|
The Cohort report for all patients that are overdue for immunizations is available to the provider through the EMR. |
| Test Objectives |
|---|
Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
The following patient information is provided on the cohort report:
|
| Notes for Testers |
|---|
No Note |
| Description |
|---|
The provider periodically uses the EMR to identify the cohort of patients that are overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents. |
| Comments |
|---|
No Comments |
| Pre Condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR. |
| Post Condition |
|---|
The Cohort report for all patients that are overdue for immunizations is available to the provider through the EMR. |
| Test Objectives |
|---|
Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
The following patient information is provided on the cohort report:
|
| Notes for Testers |
|---|
No Note |